MEDICINE P6
1. A 30 year old woman who is 12 weeks pregnant is found to be HIV positive during her first
antenatal visit. Her CD4 count is 300 cells/mm³. The most appropriate management would
be:
A. arrange for a therapeutic abortion
B. commence therapy with tenofovir, lamivudine and nevirapine
C. continue routine antenatal care and repeat tests in 3 months
D. commence therapy with zidovudine, lamivudine and boosted lopinavir
E. commence therapy with zidovudine, lamivudine and efavirenz
2. A 24 year old man presents with an acute onset of a headache, high fever and vomiting. He
had gone to Mutoko 6 weeks previously but used chloroquine prophylaxis. On examination
he has a fever, jaundice and splenomegaly. The most useful investigation is
A. Thin and thick Giemsa –stained blood smears
B. Enzyme assay for glucose-6-phosphate dehydrogenase
C. CSF examination
D. Screen for hepatitis A infection
E. Screen for HIV infection
3. A 30 year old man presents with cerebellar ataxia a week after the eruption of a generalised
rash with vesicles. Smear of fluid from the vesicles reveals multinucleated giant cells. The
most likely diagnosis is
A. Herpes zoster oticus
B. Herpes simplex encephalitis
C. Varicella zoster encephalitis
D. Meningococcal meningitis
E. Cryptococcal meningitis
4. A 20 year old female is referred for recurrent epistaxis and bruising. On examination she has
no facial rash or lymphadenopathy. Her spleen is just palpable and she has generalised
bruising. Immediate blood test results are as follows:
White cell count: 5x109/L
Hb: 10g/dL
Platelets: 25x109/L
ESR: 55mm/hr
MCV: 90 fl
MCH: 30 pg
MCHC: 34 g/dL
Prolonged bleeding time
Serum urea: 6 mmol/L
The next most useful investigation would be:
A. bone marrow aspirate
B. haemoglobin electrophoresis
C. Serum lactate dehydrogenase
D. peripheral blood smear
E. Coombs test
5. The most likely diagnosis in question 4 is
A. Thrombotic thrombocytopaenic purpura
B. Idiopathic thrombocytopaenic purpura
C. Aplastic anaemia
D. Systemic lupus erythematosus
E. Von Willebrand’s disease
6. A 60 year old man presents with acute shortness of breath and blackouts. He smokes 20
cigarettes a day and drinks socially. He is plethoric and has a raised JVP with dilated veins on
his chest wall. The most likely diagnosis is
A. Bronchogenic carcinoma
B. Chronic obstructive pulmonary disease
C. Non- Hodgkin lymphoma
D. Cor pulmonale
E. Polycythaemia rubra vera
7. A 50 year old woman presents with pain and stiffness of the joints of her hand, worse in the
mornings. On examination she has ulnar deviation of the wrists and wasting of the small
muscles of her hands. There is symmetrical swelling of the proximal interphalangeal and
metacarpophalangeal joints. The most likely diagnosis is
A. Rheumatoid arthritis
B. Psoriatic arthropathy
C. Dermatomyositis
D. Systemic lupus erythematosus
E. Osteoarthritis
8. A previously well 55 year old man presents 6 hours after the onset of severe retrosternal
chest pain. His ECG shows ST segment elevation in two adjacent chest leads. Which
immediate treatment modality is most likely to improve long term outcomes?
A. Thrombolysis
B. Anti-coagulation
C. Analgesia
D. Nitrates
E. statins
9. A 70 year old man presents with nausea, vomiting and weakness. He has been commenced
on treatment for congestive cardiac failure 4 weeks previously with frusemide, captopril and
digoxin. The most useful blood test would be
A. CK-MB and troponin
B. Serum urea and electrolytes
C. Digoxin levels
D. Serum osmolality
E. Full blood count
10. A 17 year old female presents with pallor, a tinge of jaundice and a leg ulcer. Which
investigation is most likely to give the correct diagnosis?
A. Serum vitamin B 12
B. ferritin levels
C. random blood sugar
D. peripheral blood smear
E. liver function tests
11. An HIV positive 24 year old lady presents with odynophagia. What is the most likely
diagnosis?
A. cytomegalovirus infection
B. Kaposi Sarcoma
C. Herpes simplex virus infection
D. Oral hairy leukoplakia
E. candida infection
12. A 13 year old boy is reported as having hyposplenism. Which of the following abnormalities
would you look out for on his peripheral blood film?
A. Burr cells
B. Elliptocytes
C. Spherocytes
D. target cells
E. acanthocytes
13. A young man presents with a fever and hypotension 6 months after a splenectomy. Which
one of the following organisms should be covered by the initial antibiotic therapy?
A. Staphylococcus aureus
B. Neisseria gonorrhoeae
C. Pseudomonas aeruginosa
D. Streptococcus pneumoniae
E. Escherichia coli
14. An 18 year old male patient presents with seizures. You need to prescribe an anti-epileptic
agent for him. Which seizure type is well matched with the anti-epileptic drug?
A. absence seizures: phenytoin
B. myotonic seizures: ethosuximide
C. tonic-clonic seizures: phenobarbitone
D. partial seizures: clonazepam
E. infantile spasms: carbamazepine
15. A 60 year old man who used to drink alcohol heavily presents with bullous skin lesions
involving mainly the dorsum of his hands. What is the most likely diagnosis of the skin
disorder?
A. dermatitis herpetiformis
B. pemphigus
C. porphyria cutanea tarda
D. pellagra
E. erythema multiforme
16. A 35 year old HIV positive man has chronic diarrhoea which has not responded to various
antibiotics. Which of the following possible causative organisms has no specific therapy?
A. Entamoeba histolytica
B. Giardia lamblia
C. Shigella dysenteriae
D. Cryptosporidium parvum
E. Toxoplasma gondii
17. A 14 year old girl admits to having taken a handful of some tablets from her mum’s handbag
a few hours ago. Which of the following features would most suggest that she had salicylate
poisoning?
A. Tinnitus
B. Miosis
C. Tachypnoea
D. Bradycardia
E. stupor
18. What is the commonest risk factor for developing peripheral neuropathy following
commencement of stavudine containing antiretroviral therapy (ART)?
A. anti- tuberculosis treatment
B. cannabis abuse
C. diabetes mellitus
D. malnutrition
E. anti hypertensive treatment
19. A 75 year old male ex-smoker is suspected of having a lung tumour. You discover that he has
hypercalcaemia. What is the likely diagnosis?
A. Hodgkin disease
B. Adenocarcinoma
C. Mesothelioma
D. oat cell carcinoma
E. squamous cell carcinoma
20. An HIV positive patient presents with a dry cough and breathlessness on mild exertion. He is
not obviously cyanosed. You suspect Pneumocystis jirovecii pneumonia. Which one of the
following would support the diagnosis?
A. use of cotrimoxazole prophylaxis
B. normal chest examination
C. Antiretroviral therapy for one year
D. bilateral pleural effusions
E. high fever of 40°C
21. Which is true of the malaria parasite?
A. hypnozoites occur in P.vivax infection
B. quartan fever is a feature of P.ovale infection
C. P. falciparum typically causes a nephrotic syndrome
D. gametocytes develop into schizonts within red blood cells.
E. the life cycle in the mosquito is strictly sexual
22. You order an arterial blood gas analysis on a female patient who presented acutely short of
breath. The results indicate respiratory alkalosis. What is the most likely diagnosis?
A. severe kyphoscoliosis
B. myasthenia gravis
C. gross obesity
D. asthma exacerbation
E. hyperventilation
23. You want to prescribe a bactericidal antibiotic. You remember from pharmacology that such
agents may act through inhibition of synthesis of the cell wall. Which of the following would
fit this description?
A. Amoxycillin
B. Ciprofloxacin
C. Tetracycline
D. Trimethoprim
E. rifampicin
24. A 14 year old school girl presents with a history of intermittent pain in the joints. She has a
rash on the trunk and a soft systolic murmur. Her ESR is 100. What is the diagnosis?
A. Still’s disease
B. Systemic lupus erythematosus
C. Acute rheumatic fever
D. Infective endocarditis
E. Reactive arthritis
25. You are shown a chest X-ray with “batwing shadowing” in the lungs and a normal cardiac
shadow. What clinical sign would suggest mitral stenosis?
A. Atrial fibrillation
B. sustained apex beat
C. cyanosis
D. peripheral oedema
E. apical systolic murmur
26. A 60 year old HIV positive woman presents with sudden onset of pleuritic chest pain,
shortness of breath and haemoptysis. She is hypertensive and takes cotrimoxazole
prophylaxis. The ECG shows right ventricular strain. Her blood pressure is 100/ 60 mmHg.
What is the most likely diagnosis?
A. Acute myocardial infarction
B. Acute pericarditis
C. Pneumocystis pneumonia
D. Pulmonary tuberculosis
E. Pulmonary embolism
27. A 24 year old man presents with a month’s history of a swollen right knee. He was started on
antiretroviral therapy (ART) two months ago. He was also on treatment for pulmonary
tuberculosis, which predated the ART. Pus was aspirated from the knee. What is the most
likely cause?
A. Tuberculous arthritis
B. Septic arthritis
C. Staphylococcal arthritis
D. Rheumatoid arthritis
E. Reactive arthritis
28. A female patient who has been on antiretroviral therapy (ART) for 6 months presents with
increasing shortness of breath and nausea for two weeks. She has been adherent to
cotrimoxazole prophylaxis. She is tachypnoeic but not cyanosed. Her pulse is 120 beats/min.
What is the most plausible explanation for her symptoms?
A. Pneumocystis pneumonia
B. Pulmonary oedema
C. Lactic acidosis
D. Lobar pneumonia
E. Renal impairment
29. A 75 year old lady is admitted with shortness of breath and bilateral leg swelling. She has
recently developed palpitations and has a goitre. Which one of the following tests would
confirm the cause of the cardiac failure?
A. B type natriuretic peptide
B. Echocardiography
C. parathyroid hormone levels
D. thyroid stimulating hormone
E. serum catecholamines
30. A young man presents with haemoptysis and rapidly progressive renal failure. A renal biopsy
shows antiglomerular basement membrane antibodies. What is the most likely diagnosis?
A. systemic lupus erythematosus
B. Wegener’s glomerulonephritis
C. Goodpasture’s syndrome
D. polyarteritis nodosa
E. microscopic polyangitis
31. A patient with multiple myeloma presents with worsening of her symptoms after starting
chemotherapy. Which one of the following symptoms suggests hypercalcaemia.
A. mood elevation
B. bone pain
C. increased appetite
D. diarrhoea
E. polyuria
32. A patient at the neurology clinic complains of “double vision”. His symptoms are worse when
he walks down the stairs at his work place. The most likely affected cranial nerve is the:
A. Sixth nerve
B. Third nerve
C. Fourth nerve
D. Second nerve
E. Seventh nerve
33. A 35 year old prisoner remained on anti-tuberculous therapy for longer than usual, because
of poor adherence. He now complains of a rash and diarrhoea. He has poor memory and
emotional blunting. The most likely diagnosis is
A. Tuberculous meningitis
B. Pellagra
C. drug induced hepatitis
D. vitamin B12 deficiency
E. scabies
34. A 43 year old man presented with breathlessness and mitral stenosis was diagnosed. Which
one of the following signs suggests that the valve is still mobile?
A. a fourth heart sound
B. a loud second heart sound
C. an opening snap
D. a soft first heart sound
E. a third heart sound
35. A 24 year old West African man is diagnosed with HIV-2. His CD4 count is 20 cells/mm³.
Which class of antiretroviral drugs should not be included in the treatment regimen?
A. Nucleoside reverse transcriptase inhibiton
B. Non-Nucleoside reverse transcriptase inhibitor
C. Protease inhibitor
D. Integrase inhibitor
E. CCR5 inhibitor
36. Dry blood spots used for HIV testing in infants check for:
A. HIV antibodies
B. HIV p24 antigen
C. HIV RNA
D. HIV DNA
E. HIV CCR5 receptors
37. A 55 year old woman who has been taking stavudine, lamivudine and nevirapine complains
bitterly of pricking pains in her feet and fingers. She has an undetectable viral load. She has
not responded to amitriptyline and pyridoxine over the past 3 months. What would you
advise her?
A. Place her feet in cold water every evening for relief
B. Use regular non-steroidal anti-inflammatory agent
C. Use regular morphine therapy
D. Switch to second line therapy.
E. Switch stavudine to tenofovir
38. An elderly couple is found unconscious in a hut in July. You suspect carbon monoxide
poisoning. Which investigation would confirm the diagnosis?
A. High haemoglobin level
B. High carboxyhaemoglobin levels
C. High carbon dioxide concentration.
D. High oxygen saturation.
E. High haematocrit.
39. A 60 year old diabetic and hypertensive patient presents in renal failure. Which of the
following features would make you suspect diabetic nephropathy?
A. Bilateral leg swelling
B. mild proteinuria
C. cataracts
D. Low serum calcium
E. A high potassium
40. An elderly patient presents with pain in the hand at night. She has Type II diabetes and
longstanding rheumatoid arthritis. What is causing the pain?
A. Peripheral neuropathy
B. Carpal tunnel syndrome
C. Mononeuritis multiplex
D. Thoracic outlet syndrome
E. Angina pectoris
41. A 21 year old man presents with difficulty in walking and urinary incontinence. He has
hyperreflexia and a sensory level at T4 level. Which radiological investigation would be most
useful?
A. Plain thoracic spinal x-ray
B. Chest x-ray
C. Plain lumbosacral spinal x-ray
D. Myelogram
E. Thoracic MRI
42. A patient is unable to extend their elbow. Which nerve root is likely to be affected?
A. T1
B. C7
C. C8
D. C5
E. C6
43. A teenager is admitted from the Kaposi Sarcoma Clinic with purple nodular lesions. The
lesions are improving on doxycyline started after a histological diagnosis two weeks
previously. What special stain was used on the tissue sample?
A. Haematoxylin & eosin staining
B. Warthin Starry staining
C. India ink staining
D. Methanamine-Silver staining
E. Immunofluorescent staining
44. Haemolytic anaemia due to red cell membrane disorder is best exemplified by:
A. sickling disorders
B. thalassaemia syndromes
C. Rh and ABO incompatibility
D. hereditary spherocytosis
E. paroxysmal nocturnal haemoglobinuria
45. With regard to valvular heart disease:
A. hypocalcaemia is known to be associated with supravalvular aortic stenosis
B. an early systolic murmur is a feature of mitral valve prolapse
C. the Graham Steell murmur occurs in aortic regurgitation
D. the Carey Coombs murmur is a diastolic murmur heard in acute rheumatic endocarditis
E. a mid-systolic murmur is typical of mitral regurgitation in rheumatic valve disease
46. A 40-year –old actor with insulin- dependent diabetes mellitus collapses after starting
propranolol for stage fright. He has not changed his insulin regime.His glucose is 1.5mmol/L.
The most beneficial advice you would offer him after emergency treatment would be
A. discontinue propanolol
B. carry a chocolate bar
C. decrease his isophane insulin
D. decrease his actrapid insulin
E. switch to oral hypoglycaemics
47. A 20-year old man presents with buttock pain radiating down both legs and heel pain. On
examination he has marked kyphosis and limitation of chest expansion. ESR and C-reactive
protein (CRP) are raised. The most likely diagnosis is
A. A lumber disc prolapse
B. sacro-iliitis
C. spondylolisthesis
D. spinal stenosis
E. ankylosing spondylitis
48. A 30-year old man from Chiredzi is noted to have a pansystolic murmur heard best at the left
lower sternal edge. Giant ‘cv’ waves are present in the jugular venous pulse. He has a
pulsatile hepatomegaly. The most likely diagnosis is
A. ventricular septal defect
B. pulmonary regurgitation
C. pulmonary hypertension
D. tricuspid regurgitation
E. mitral regurgitation
49. A 23-year- old woman complains of general fatigue, muscle aches and double vision. She
tires easily from talking. On examination she has bilateral ptosis, but the pupils are equal and
reactive to light. The most discriminating investigation would be
A. thyroid function tests
B. antinuclear antibodies
C. smooth muscle antibodies
D. lumber puncture
E. anti-acetylcholine receptor antibodies
50. A 45-year- old man with a history of epilepsy presents with several weeks of fluctuating
levels of consciousness.On examination his pupils are equal . The most discriminating
investigation is
A. HIV serology
B. computerised tomography [CT Scan]
C. electroencephalogram
D. drug levels
E. lumbar puncture
51. A 35 year old man with insulin dependent diabetes presents to casualty with a cough, fever,
vomiting and abdominal pain. On examination he is dehydrated, pyrexial and has bronchial
breath sounds in the right axilla. Urinalysis shows ketones ++++. Investigations show mildly
raised urea, creatinine and potassium with a metabolic acidosis. Which of the following
should not be administered during his treatment?
A. Intravenous fluids
B. Bicarbonate
C. Parenteral potassium
D. Antibiotics
E. insulin
52. A 65 year old man with controlled hypertension presents with a history of sudden onset
weakness of his left arm which resolved completely over 12 hours. He had two similar
previous episodes. He was in atrial fibrillation with a ventricular rate of 85 beats per minute.
A CT scan of the brain was normal. What is the most appropriate management?
A. Amiodarone
B. Digoxin
C. Nifedipine
D. Low-dose aspirin
E. Warfarin
53. A 63 year old patient who presented with ascites, abdominal tenderness and peripheral
oedema. He had a history of excessive alcohol consumption. Investigation of the ascitic fluid
revealed a neutrophil count of 400/mm³ (<250/mm³). Which of the following would be of
most immediate benefit?
A. Salt restriction
B. Intravenous antibiotics
C. Oral spironolactone
D. Therapeutic paracentesis
E. Fluid restriction
54. A patient is suspected of having acromegaly. What is the best investigation to confirm the
diagnosis?
A. A glucose tolerance test with growth hormone concentrations
B. A growth hormone releasing hormone test
C. An insulin tolerance test with growth hormone concentrations
D. Basal growth hormone concentrations
E. Insulin-like growth factor
55. A 73-year old man presented with an acute attack of gout in his left knee. What is the most
likely underlying metabolic cause?
A. Decreased renal excretion of uric acid
B. deposition of uric acid crystals in joints
C. Excessive dietary purine intake
D. Lactic acidosis
E. Starvation
56. A 19 year old female developed bilateral pleural effusions, ascites and ankle swelling. Her
blood pressure was 112/76 mmHg. Investigations revealed: Serum alanine transferase 17 u/l
(5-35) Serum total bilirubin 17µmol/l (1-22) Serum albumin 21 g/l (37-49) Serum total
cholesterol 9.8mmol/l ( <5.2) What is the next most appropriate investigation?
A. Antinuclear antibody
B. Pregnancy test
C. Prothrombin time
D. Serum protein electrophoresis
E. Urinary protein estimation
57. A 22 year old woman presented with a 3 week history of severe episodic headaches and
diminished vision affecting the right eye. She had gained considerable weight over the
previous year. She was HIV negative. On examination she had bilateral papilloedema. What is
the most likely diagnosis?
A. Benign intracranial hypertension
B. Bilateral optic neuritis
C. Hypothalamic tumour
D. Sagittal sinus thrombosis
E. Thyroid orbitopathy
58. A 55 year old man presented with gynaecomastia while receiving treated for dilated
cardiomyopathy. Which of the following drugs is commonly associated with the development
of gynaecomastia?
A. Amiloride
B. Nifedipine
C. Captopril
D. Frusemide
E. Spironolactone
59. Which of the following can cause miliary shadowing on a chest x-ray?
A. Wegener’s granulomatosis
B. Metastatic renal cell carcinoma
C. Polyarteritis nodosa
D. Mitral stenosis
E. Staphylococcal pneumonia
60. A 52 year old man presented with sudden onset of blindness in one eye. Where is the lesion?
A. Occipital lobe
B. Optic chiasma
C. Optic nerve
D. Optic radiation
E. Optic tract
61. What is the most likely outcome of poststreptococcal glomerulonephritis at 16 years of age?
A. A tendency to relapse
B. Full renal recovery
C. Permanent renal impairment
D. Persistent hypertension
E. Persistent proteinuria
62. A 38 year old nursery school teacher presents with jaundice. Investigations reveal; Aspartate
aminotransferase 2000iu/l (1-31) Hepatitis A IgG positive Hepatitis BsAg negative Hepatitis B
core antibody positive. What is the most likely diagnosis?
A. Hepatitis A
B. Hepatitis B
C. Hepatitis C
D. Hepatitis D
E. Hepatitis E
63. A 65 year old woman was admitted for a fractured neck of femur. She was pale, with a
tippable splenomegaly and small discrete axillary lymphadenopathy. Investigations revealed:
Haemoglobin 10.7 g/dl (11.5-16.5) White cell count 34.5 (4-11) Platelets 183 (150-400) What
is the most likely diagnosis?
A. Acute myeloid leukaemia
B. Chronic lymphatic leukaemia
C. Chronic myeloid leukaemia
D. Myelodysplasis
E. myelofibrosis
64. In a patient with ascites:
A. A fluid thrill is more sensitive than shifting dullness
B. Constrictive pericarditis may be a cause
C. a transudate is suggestive of TB peritonitis
D. AAFB are usually identified in the fluid in TB peritonitis
E. Ascites associated with cardiac failure is usually exudative
65. A 52-year-old man complains of food sticking on its way down when he swallows.
A. Dysphagia for both liquids and solids from the outset suggests oesophageal carcinoma
B. If the symptom is due to oesophageal candidiasis, it is likely to be painless
C. Left atrial enlargement due to mitral stenosis can cause this symptom
D. If the symptom is due to an oesophageal ulcer, it is likely to be painless
E. His gender and age make oesophageal carcinoma unlikely
66. A 60 year old female has proximal muscle weakness. She has a purple rash on her face.
Investigation shows a positive anti-jo1 antibody, and negative dsDNA. What is the most likely
diagnosis?
A. Systemic lupus erythematosus
B. Hypokalaemia
C. Hyperthyroidism
D. Dermatomyositis
E. Cushings syndrome
67. Which one of the following abnormalities would confirm a diagnosis of
phaeochromocytoma?
A. Calcification of the adrenal glands on abdominal X ray
B. adrenal mass on CT scan of the abdomen
C. hypokalaemia
D. Raised urinary vanillyl mandelic acid
E. Unexplained hypertension
68. Which of the following physical signs would be seen in a patient with left sided cerebellar stroke?
A. Dysphasia
B. Hypertonia
C. Nystagmus, maximal on gaze to the left
D. Positive Romberg’s test
E. Resting left sided tremor
69. Each drug is paired with an important side effect. Which is incorrect?
A. Metformin and diarrhoea
B. Glibenclamide and hypoglycaemia
C. Glibenclamide and weight gain
D. Metformin and weight gain
E. Captopril and cough
70. The earliest sign of diabetic nephropathy is:
A. Microscopic haematuria
B. Small shrunken kidneys
C. Diabetic retinopathy
D. Elevated creatinine
E. Microalbuminuria
71. The following clinical signs suggest a spinal cord lesion:
A. Bilateral paraesthesiae
B. Sensory level
C. Normal micturition control
D. Nystagmus on lateral gaze
E. Absent plantar response
72. Regarding seronegative arthropathies
A. Ankylosing spondylitis is associated with HLA-DR4
B. psoriatic arthritis typically causes distal interphalangeal arthritis
C. Reiter’s disease comprises arthritis, urethritis and scleritis
D. Amoebic dysentery can be complicated by reactive arthritis
E. Arthritis occurs in 20% of patients with ulcerative colitis
73. The most accurate pairing of the association of the tumour and its circulating marker is
A. ovarian carcinoma and CA 125
B. hepatoma and CA 153
C. small cell carcinoma and ACTH levels
D. medullary thyroid carcinoma and thyroglobulin
E. osteosarcoma and PTH-related peptide
74. The following are consistent with hypokalaemia
A. peaked P waves
B. widened QRS complex
C. ST-segment elevation
D. short PR interval
E. U waves
75. The following parameters are examples of measures of central tendency except
A. mean
B. range
C. average
D. median
E. mode
